Question

Case Description

You are a floater pharmacist working at a new pharmacy on the weekend in the outskirts of an urban area. Towards the end of the day, Ben approaches your pharmacy counter with a new prescription for Percocet 10/325 #60 with directions to take 1-2 tablets every 4-6 hours as needed for severe pain from Dr. Stevens at the local urgent care facility. Ben states that he has just been in a multi-car accident, and is suffering from back and leg pain. Since he is a new patient, he is asked to provide more comprehensive medical information. In addition, a new state law requires prospective review of the prescription drug monitoring program (PDMP) before dispensing any opioid prescription. You complete review of Ben’s PDMP report (see below) and ask him about it. Ben reports that he has been working as a temporary concrete layer, and does not have benefits. He had been covered by Medicaid, but since moving to North Dakota, he hasn’t applied for it. He reports that he frequently experiences pain associated with his work. His medical information is below.

Age: 39 years

Past medical history: depression, anxiety, attention deficit disorder, alcohol use disorder, allergic rhinitis

Family history: mother (alive) with type 2 diabetes, depression, and hypertension; father (deceased) with history of alcohol use disorder, hypertension, cirrhosis

Social history: tobacco use (+); alcohol (+), living alone and not in the same city as the rest of his family

Medications: sertraline 50 mg daily; alprazolam 1 mg TID; cetirizine 10 mg daily (OTC)

PDMP Record:

Medication and dose	Instructions	Quantity (date)	Refills remaining	Prescriber	Pharmacy
hydrocodone/acetaminophen 7.5/325	1 tab every 4-6 hours prn pain	15 (10 days ago)	0	Smith	ABC
Hydrocodone/acetaminophen 7.5/325	1 tab q6 prn pain	30 (15 days ago)	0	Jones	123
Methylphenidate 10 mg	1 tab BID	60 (15 days ago)	0	Jones	123
hydrocodone/acetaminophen 5/325	1 tab every 4-6 hours prn pain	30 (20 days ago)	0	Hite	XYZ
Alprazolam 1 mg	1 tab TID	90 (20 days ago)	1	Hite	XYZ

10. Will you dispense the Percocet for Ben? Why or why not?

11. What treatment options are recommended for this patient to reduce harm? Who else needs to be included in the treatment plan discussion? What can be done today?

13. What are the discussion points that need to be conveyed to the patient and caregivers, including opioid safety and medication use?

14. Part II of this case study has explored options for controlling opioid misuse on the population and the individual level. Write a half- to one-page summary of the roles of the PDMP and screening using the ORT to reduce opioid misuse on an individual and a population level.

Answer 1

10. Percocet is a combination of opioid pain reliever( narcotic) oxycodon and non opioid pain reliever aceraminophen. So as the prescribed medicine is a combination of acetaminophen and hydrocodone so percocet will not be dispensed.

NOTE-PERCOCET exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Percocet may interact with other narcotic pain medications, sedatives, tranquilizers, sleeping pills, muscle relaxers, other medicines that can make you sleepy or slow your breathing, so as Ben is taking alprazolam it can react with it.

11.Deterrent agents
The deterrent agents are also known as alcohol sen-
sitising drugs.
Disulfi ram (tetraethyl thiuram disulfi de) was dis-
covered in 1930s, when it was observed that workers
in the rubber industry developed unpleasant reactions
to alcohol intake, due to accidental absorption of
antioxidant disul fi ram.

Other deterrent agents
1. Citrated calcium carbimide (CCC): The mecha-
nism of action is similar to disulfi ram but onset of
action occurs within 1 hour and is reversible. The
usual dosage is 100 mg/d in two divided doses.
2. Metronidazole.
3. Animal charcoal, a fungus (Coprinus atra men -
tarius), sulfonylureas and certain cephalos porins
also cause a disulfi ram like action.
v. Anti-craving agents
Acamprosate, naltrexone and SSRIs (such as fl uoxet-
ine) are among the medications tried as anti-craving
agents in alcohol dependence.
Acamprosate (the Ca++ salt of N-acetyl-homo taurinate)
interacts with NMDA recep tor-mediated glutamater-
gic neurotransmission in the various brain regions
and reduces Ca++ fl uxes through voltage-operated
channels.
Naltrexone (oral opioid receptor antagonist) prob-
ably interferes with alcohol-induced reinfor cement
by blocking opioid receptors. Fluoxetine (and other
SSRIs) have been occasionally used as anti-craving
agents in their usual antidepressant doses.
vi. Other medications
A variety of other medicines such as benzodia-
zepines, antidepressants, antipsychotics, lithium,
carbamazepine, and even narcotics have been tried.
These should be used only if there is a special indi-
cation for their use (for example, antidepressants for
underlying depression).
vii. Psychosocial rehabilitation
Rehabilitation is an integral part of the multi-modal
treatment of alcohol dependence.

Acetaldehyde Acetate CO2 + H2O Ethyl alcohol Metabolism Aldehyde dehydrogenase (enzyme) Increased blood acetaldehyde levels Disulfiram Metabolised to Diethyldithiocarbamate Increased brain dopamine levels Dopamine B-hydroxylase (enzyme) OL DOPA Dopamine Norepinephrine Epinephrine

14.PDMP is a statewide electronic database that stores prescribing and dispensing records related primarily to
medications classified as Federal controlled substances,

Benefits of a PDMP
1) For Prescribers
PDMPs contribute to the continuity of care among providers working in a variety of practice settings such
as primary care, pain management, and substance abuse care. These databases help providers by increasing .
awareness of all active controlled substance medications on file for a patient. PDMPs also help providers safely
and effectively treat chronic pain. PDMPs may alert prescribers to patients obtaining prescriptions from multiple
doctors or pharmacies (known as “doctor shoppers”) and may deter patients from doctor shopping.[6] Prescribers
can use PDMP data as a tool to monitor compliance and increase confidence in prescribing decisions.

For Pharmacists
PDMPs help pharmacists ensure that patients who are treated for legitimate, chronic pain maintain access to
essential medications. The databases can help identify at-risk patients who may benefit from a pharmacist-initiated
counseling session or patients who may be candidates for a referral for lock-in to one dispenser or provider.
PDMPs can raise a red flag that alerts a pharmacist to prescriptions likely to enter the illicit market. PDMPs may
also help pharmacists identify questionable prescriber patterns that warrant referral for further investigation.
For Patients
PDMPs protect patient privacy while decreasing the incidence of opiate exposure or overdose related to misuse
and abuse. PDMP data may draw a prescriber’s or dispenser’s attention to life-threatening controlled substance
interactions that pose a risk to patients managed by more than one prescriber. Identified at-risk patients may be
deterred from drug misuse or abuse. Identifying an at-risk patient may encourage the patient to seek help, and
the patient can be referred for treatment if desired. However, proactive analysis and distribution of PDMP data
may reduce the need for substance abuse treatment admissions. PDMPs may also alert patients to prescriptions
fraudulently billed in their name. PDMPs used effectively may benefit patients by preserving their access to
appropriately utilized prescription-based therapy.[7]
For Regulatory and Law Enforcement Agencies
PDMP data may help regulatory and law enforcement agencies in a variety of ways. Identifying patterns provides a
resource to target areas for further investigation. Data may identify patients who exhibit questionable patterns of
obtaining and filling prescriptions for controlled substances or prescribers who exhibit patterns of overprescribing
controlled substances. Overprescribing indicators may reveal a pill mill—a medical practice or other health care
facility “that routinely conspires in the prescribing and dispensing of controlled substances outside the scope of
the prevailing standards of medical practice”[8]—or may expose patterns of insurance fraud. In addition, PDMP
data may reduce the amount of time spent on drug diversion or fraud investigations. As a result, the costs of
regulatory and law enforcement agencies are reduced. PDMP data may also assist regulatory and law enforcement
agencies with monitoring compliance and abstinence.[9]
Maximize Efficiency and Improve Patient Care by Using a PDMP
Consider the following actions to maximize the efficiency and effectiveness of PDMPs:
• Become familiar with the State’s specific compliance and reporting requirements and follow them;
• Offer data submission and retrieval training to qualified personnel;
• Incorporate PDMP database screening into workflow schematics; and
• Integrate PDMP monitoring into voluntary, comprehensive compliance programs to maximize PDMP use
and improve patient care by reducing prescription drug diversion, misuse, and abuse.

@OPIOID RISK TOOL-

The Opioid Risk Tool (ORT) is a brief, self-report screening tool designed
for use with adult patients in primary care settings to assess risk for opioid
abuse among individuals prescribed opioids for treatment of chronic pain.. The ORT is a 5-item validated questionnaire designed to predict the risk of problematic drug-related behaviors (PDRB). A score of 8 or higher is considered high risk for opioid misuse